<p>ENVIRONMENTAL LINES GREENWORKS INSURANCE – Microbial Matter Coverage - Supplemental Application Page 1 of 3</p><p>BROKER INFORMATION Name: Contact: Address: City: Postal Code: For renewal only, Policy Number: Applicant: </p><p>1. For the past 5 years, are you aware of or do you have reasonable knowledge of any known incidents, claims or other circumstances concerning the existence, growth or presence of microbial matter in any of your previous work? YES NO If YES, please describe: </p><p>2. Do you have a written reporting procedure for water leaks or mould issues at a job site? YES NO Please describe or attach details: </p><p>3. Do you have an established Standard Operating Procedure (SOP) and/or written Quality Assurance Plan / YES NO Protocols designed to prevent microbial matter growth and detailing microbial matter inspections or removal/remediation of any microbial matter contamination? Please describe or attach details: </p><p>4. Do you have a written procedure for handling mould or mould-related complaints? YES NO Please describe or attach details: </p><p>5. Do you perform inspections on building materials upon delivery for pre-existing mould contamination? YES NO Please describe or attach details: </p><p>6. Do you conduct training for laborers and/or subs on microbial matter prevention? YES NO Do they attend Third Party courses and/or training? YES NO Please describe or attach details: </p><p>7. When using subcontractors, do you obtain written verification that the sub is certified in Mould Remediation or YES NO Mould Awareness? Please describe or attach details: </p><p>8. Do you request certificates of insurance verifying insurance coverage for microbial matter from subcontractors? YES NO Please describe or attach details: </p><p>9. Do your construction/consulting contracts contain any disclaimers or limitation of liability for the existence of YES NO mould? Please describe or attach details: </p><p>10. Do you enter into any other legal agreements whereby you contractually assume liability for mould not otherwise YES NO imposed by law? Please describe or attach details: </p><p>11. Do you subcontract the analysis of mould to a Third Party laboratory? YES NO Please describe or attach details: </p><p>Rev. Oct 21, 2014 ENVIRONMENTAL LINES GREENWORKS INSURANCE – Microbial Matter Coverage - Supplemental Application Page 2 of 3</p><p>Rev. Oct 21, 2014 ENVIRONMENTAL LINES GREENWORKS INSURANCE – Microbial Matter Coverage - Supplemental Application Page 3 of 3</p><p>For purposes of the Insurance Companies Act (Canada), any document would be issued in the course of Lloyd’s Underwriters’ insurance business in Canada. Where (a) an Applicant for this contract gives false particulars to the prejudice of the insurer or knowingly misrepresents or fails to disclose any fact in any part of this application required to be stated therein; or (b) the insured contravenes a term of the contract or commits a fraud; or (c) the Insured willfully makes a false statement in respect of a claim, a claim will become invalid and the Insured’s right of recovery is forfeited. The Applicants have reviewed all parts and attachments of this application and acknowledge that all information is true and correct and understand that this application for insurance is based on the truth and completeness of this information. I have provided personal information in this document and otherwise and I may in the future provide further personal information. Some of this personal information may include, but is not limited to, my credit information and claims history. I authorize my broker or insurance company to collect, use and disclose any of this personal information, subject to the law and my broker’s or insurance company’s policy regarding personal information, for the purpose of communicating with me, assessing my application for insurance and underwriting my policies, evaluating claims, detecting and preventing fraud, and analyzing business results. I confirm that all individuals whose personal information is contained in this document have authorized that I agree to the above on their behalf.</p><p>Applicant’s Name: Applicant’s Signature: Date: </p><p>** Email application and attachments to - [email protected] ** Vancouver - T 604.669.5211 F 604.669.2667 Toronto - T 416.365.0444 F 416.365.0446 London - T 519.850.1610 F 519.850.1614</p><p>Rev. Oct 21, 2014</p>